Aligning care, sharing risk
Along with mental illness – cancer, heart disease, diabetes, and other chronic diseases account for 90% of the nearly $5 trillion in annual U.S. healthcare expenditures. Alarmingly, four in 10 Americans have two or more chronic diseases. Episode-based care models such as TEAM can be particularly effective in treating polychronic patients who interact frequently with primary care providers and multiple specialists.

Efficient program design and communication are critical to the success of episode-based care models. Risks and incentives, referral patterns, how information is to be shared – these elements of an episode-based program must be clear to all participants.
Data analytics can be leveraged to define and optimize episode-based models. Population health analytics and predictive modeling enable specialists to understand cost drivers and performance metrics under their contracts, improving their chances of success.

VBC contracts can include separate episode-based pricing models for different specialties, such as orthopedics and oncology. They also can opt for an enterprise-based cost model that may work for all participating providers.

In addition to aligning primary and specialty care, it is important in designing episode-based networks to align inpatient care with post-acute care. Patients who are discharged either too early or inappropriately can drive significant costs of care, up to and including readmission.

By standardizing referral pathways and sharing data in real time, participants in episode-based programs can improve outcomes while reducing unnecessary costs. Standardized clinical pathways within specialty care can improve efficiency, optimize patient care, and enhance the ability of specialists to participate in risk-based programs.

Care coordination relies on optimized networks that ensure data is shared and appropriate services are available and efficiently utilized. A cloud-based digital infrastructure can support effective communication and collaboration between primary care providers and specialists. Not only does the right infrastructure and model design improve patient outcomes, it creates a better experience for care teams.

Finally, as organizations move forward with episode-based pricing models, payers increasingly recognize the value of coordinated care networks that include specialists in delivering better health outcomes while controlling costs and resource utilization.

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